Common Sense Look at Marijuana as a Gateway Drug

Preface

The following essay takes a critical look at marijuana as a gateway drug, its ambiguous role in society and what this means in day to day practice. If we actually care about problems in the world related to substance use, we have to phrase the problem correctly and take many other factors into account. I begin by posing a few questions to help us understand what we actually mean by “gateway” followed by a discussion about how one might look for evidence of this in the data that we have.

Corpus

Is the term gateway meant to be a cautionary label? Where do the concepts of dependence and gateway overlap? The term gateway implies a transition from one category of drug use to another. To make the gateway argument work, we have to think about it in terms of the desire to achieve more effective qualities of mind alteration. i.e. dependence. You could also make the case that marijuana is the first stepping stone among many in the pursuit of higher highs. Using this low-resolution description, we still have to contend with the assumption that by removing the “first stepping stone”, we could somehow reduce future use of other illicit substances. I see no evidence of that and rates of marijuana use by 12th graders today are still only half what they were in 1978 (Hart & Ksir, 2014 p.7) yet we still currently have fluctuating issues with hard drugs in the U.S. We would also expect to see marijuana trend lines marionetting the use trends of other illicit drugs.

Percentage of College Students One to Four years beyond High School Reporting Use of Seven types of Drugs

Source

The graph above shows us several important things. First, the most used substance over the past 30 days is overwhelmingly alcohol by a factor three times more than that of marijuana. Interestingly, when we move the scope to everyday use, we find tobacco use exceeding that of both marijuana and alcohol which are nearly on par with one another. While daily use of marijuana is higher than alcohol, we hardly see any effect on the use of other substances and even less on the daily use scale. If marijuana allegedly pushes people in the direction of other drugs, it’s not reflected here. Also, data derived from college-age students is significant because if we accept that marijuana use begins sometime before the age of 18, we should see an interesting transition to other substances on graphs designed to monitor the use of specific drugs in those populations. I don’t think I’m using the wrong metric here. I see alcohol, tobacco, and marijuana remaining steadfastly popular with other drug use happening within a very small minority of people. And, if there is a significant correlation between the three most prevalent substances, the data we have can’t say which one of the three or combination thereof could explain the gateway phenomenon.

(SAHMSA, 2013) says, “More than half of new illicit drug users begin with marijuana”. So, if someone tries crack cocaine at the age of 35 and reports having used marijuana at age 15, are we also to assume that trying marijuana is ultimately what set him on a twenty-year path that could not have resulted in anything other than the use of crack? I could see this being the case in the small proportion of people with bipolar I disorder. But what about trauma? Lack of education? Criminal influences? Incarceration? Mental disorders? Why are we forgoing the kinds of questions needed to explain why humans do the things they do? Maybe it’s as simple as: people who are likely to take the risk of experimenting with marijuana are also of the sort to take risks in general. That seems like a psychologically (and biologically) sound explanation to me – adolescence!

Let’s think of this problem another way. Remember that the use of alcohol has an inhibitory effect across cognition, emotion and motor output (Hart & Ksir, 2014 p. 203). Suppose I wanted to make the argument that because of these effects, alcohol causes people to become more violent or dangerous. It would be positively fatal to my master’s thesis if I actually tried to imply causation to something in this way despite the fact that we see alcohol as a common factor in many (maybe most) violent crimes (NIH, 2000). I have to think about the cause and effect of behavioral traits such as aggression in terms of pre-existing proneness and a combination of other things like age, sex, background, etc. The same principle would have to apply to the issue of marijuana as a gateway drug in its most general sense. What I see is a buzzword that’s carried a lot of political gravitas over the years but has yet to explain much of anything about marijuana’s actual role in society. The jury is arguably still out for deliberation in that regard.

My most honest answer to whether or not I believe marijuana is a gateway drug is: “I don’t know”. Why do antidepressants make some people more depressed and suicidal? But, that fact still doesn’t compel me to strip them from the market altogether or assume that this side effect happens in more than just a small minority of people who take them.

What are we really talking about here? The real dangers of marijuana can be delineated readily. There's no conspiracy to cast smog over otherwise legitimate health concerns.

Marijuana raises heart rate (Hart & Ksir, 2014 p. 364) which is obviously hazardous to hundreds of thousands of people who suffer from heart attacks each year (CDC, 2017).

Marijuana impairs coordination (Hart & Ksir, 2014 p. 359) in similar ways to alcohol and we don’t want people operating heavy machinery under its influence.

In a more recent assignment, I described how the use of marijuana can actually trigger the onset of psychosis in individuals who are genetically prone to developing schizophrenia (Kaminer, 2016).

…Causes anxiety (Hart & Ksir, 2014)

…Diminishes sperm count (2014)

…Is implicated in diseases of the respiratory system similar to that of long-term tobacco use… (2014)

These are just a few of the concerns I would have when evaluating clients in the future. At the very bottom, it would be inadvisable to recommend that anyone inhale combustible material. Some people are going to choose to do these things anyway. Our job as future practitioners in this field is to facilitate change in a myriad of ways including general risk reduction. If someone quits drinking alcohol and begins smoking marijuana instead, I would not tell them it would be better to go back to drinking alcohol but I wouldn’t encourage long-term use of marijuana either. If I took the gateway concept seriously I would have to be concerned that this particular alcoholic will now be putting themselves at risk for other drug use from that point forward. It’s not clear to me that he wasn’t at risk for other drug use to begin with.

Lastly, why is the transition from legally prescribed opiates to heroin use and subsequent fentanyl use of no concern? Isn’t it true that some people who originally take opiate medication for pain find themselves helplessly “crossing the gate”, as it were, into a world of more potent drugs? Even then, we cannot place the blame squarely at the feet of the pharmaceutical industry or the pills themselves. We have to talk about these things using well-established systems analysis. In psychology, we break the problem down into smaller pieces and examine the relationships between them at the level of genes, mental health, and the environment.

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AUTHOR

Jessie Watson

6 weeks agofrom Wenatchee Washington

I think it's also important to avoid having a dichotomous attitude toward drugs and those who use them. Human beings are creatures capable of a wide range of experiences and thus different range of relationships with drugs. 80 percent of people who mess around with drugs can do so without disturbing the homeostasis in their lives because they don't live as "all or nothing" people . It's possible. And, yes, the brain is a sensitive organ but it's also very plastic and not completely understood.

AUTHOR

Jessie Watson

6 weeks agofrom Wenatchee Washington

We could think of addiction as a colloquialism for dependence which is actually a psychiatric term that describes a wide range of behavioral criteria in addition to - but not limited to - physical tolerance/withdrawal symptoms.

Most people think of addiction as having had one too many cheese samples at Costco or bingewatching their favorite TV shows on netflix. "Oh, that show is so addicting!".

What they mean is, they've found sufficient meaning in something that they've allowed to take up a certain percentage of their finite time here on this planet. We make compromises with ourselves like this all the time. It's not obvious which indulgences are actually creating the most disorder in our lives. Some people tend to value work as one of the ulitmate virtues yet someone can let work totally conquer their lives and is palplably the case for many Americans who work more than 40 hours a week. I suppose that works if you're a driven career person with no family waiting around the dinner table for you to come home.

None of these issues are straightforward at all. Why is it not advisable to recommend that people use amphetamines but is totally okay to prescribe to children for ADHD? Why is it wrong for someone with PTSD to self medicate with marijuana when the "legal" alternatives like Xanax actually come with more health risks? You hit the nail on the head when you said that "legal" doesn't mean "right". Alcohol is another great example of that.

Even so, I don't recommend prohobition of anything because I believe people have the right to their own consciousness and the right to self-medicate. That's just my political and philosophical stance on it. But it's inspired by the fact that drugs have been immensely powerful life savers and problem solvers.

There are also plenty examples of people who integrate substances into their lives as a means for personal exploration. Hullcinogens have been pivotal in my spiritual life as guides to my inner world. Research has picked up again MDMA, Iboga, and Psilocybin are showing some interesting implications in the aid of smoking cessation, end of life depression therapy, PTSD, and addiction in general.

I believe theres a passage in the holy bible that says something to the effect of: "the poor will always be with us". A great percentage of people who do suffer from the grips of addiction also suffer from co-ouccring mental disorders and its never clear which problem is most primary because the symptoms of these disorders generate behaviors that reinforce drug use while the drug use refinorces the symptoms of the disorder. It's a web of hell that befalls a certain chunk of the population. Comorbidity with Substance Use Disorder has the most dismal relates for relapse and clinical recitivism. There's almost nothing we can do for these people other than try to keep them stable with medication and emphasize risk reducation and relapse prevention rather than pure abstinence.

That's a very interesting piece of information with regard to anesthesia and marijuana users. You're sure that they're only using marijuana? What other drugs might interact with the nervous system in the same way? GABA agonists maybe? Benzos, sleep aids, alcohol? I'd wanna rule those out too. After a decade of drinking alcohol, I found myself very physically tolerant to most things that would lay an average person flat on their face.

We can have a discussion about what things like addiction or recreational use actually mean. Maybe we have to go back further in the timeline of human history to discover what the role of substances have been for both individuals and societies. Personally, I think the problem of drug use, in general, has been a

bit overstated. I've spent the last few years trying to dig into the issue of the human condition and drug use and, to my chagrin, have found that a lot of these notions we have as a culture are just wrong.

Here's an example: There's actually no such thing as "meth mouth". No research shows a directly link of meth use to the rotting of teeth. What explains the rotten teeth is a combination of personality traits (which also have genetic markers) and social influences that increase the likelihood that someone will abuse drugs and neglect personal hygiene.

Leland Johnson

6 weeks agofrom Midland MI

I also have concerns about correctional institutions and the system as a whole, but that's another story. Again, I question the statistics. If 80% of drug users aren't addicted why are they using? What constitutes addiction? As you point out, addiction is a uniquely complex human issue. For that reason we should not be quick to accept recreational drug use. Drugs, as you know, affect the brain, an incredibly sensitive organ. Most of the time the impact of drug use is not discovered until years later. That's another reason I have trouble accepting the data- the issue simply hasn't been studied long enough. Opiates artificially create stimulae the brain creates naturally when naturally triggered. There's a reason endorphines are created when, and not before, the body has exerted itself to the point of endorphin/serotonin release. Artificial reproduction of these powerful chemicals will not and does not happen without consequences, one being the creation of an addiction. As I said earlier, it's one of the reasons runners want to continue running. It's the brain, not the muscles, that demands the runner to run more, faster, and farther. The last point I'd like to make is coming from the view point of someone who has worked in surgery for 30 years. I can tell you that patients who smoke marijuana on a routine basis have a much more difficult time with anesthesia intra and postoperatively. I have specifically asked colleagues in anesthesia about this and they assure me it is true, an assurance I really didn't need since I've observed it first-hand many times, but THEY are the experts so I wanted to hear it from them. You never hear about that aspect of marijuana use. Patients require more anesthesia since they have built up a tolerance with marijuana. This leads to more difficulty in anesthetic re-emergence as well as intraoperative airway issues. There is so much more to this issue than our personal preferences or even rights. Thanks for responding.

AUTHOR

Jessie Watson

6 weeks agofrom Wenatchee Washington

AB Williams,

I have no doubt that it can ruin people but that's not the rule. I'm the rule.

Did you know that 80 percent of people who use illicit drugs actually do not suffer from addiction?

Sometimes its easier to phrase the question another way...

Why doesn't everyone always use drugs all the time? It's because most people find greater reward in the long-term by sacrificing short-term rewards. That's how it looks to me and without that, the world would be much more dysfunctional than it is now.

A B Williams

6 weeks agofrom Central Florida

Congratulations on your recent marriage and thank you for your service to this Country Jessie.

You may be the exception to the rule, I've just seen it ruin lives.

Merry Christmas to you and yours!

AUTHOR

Jessie Watson

6 weeks agofrom Wenatchee Washington

Leland,

I appreciate the history lesson. I don't pretend to know what the long-term outcome of legalization will be but I don't think it's going to be mayhem. Even before medical legalization began, these numbers were about as high as they are now. At least the state regulations force businesses to chemically screen and ensure safe products. I don't think it will create more users, it just creates another option to an existing market that was once ruled by criminals. Also, the presence of drugs won't equal the presence of dependence or addiction. You can't get a bunch of people addicted just by running around pricking them with a syringe full of heroin. It's not that simple, unfortunately. Addictions is a very uniquely complex human issue.

I also agree with you about Big Pharma's role in the opiate problem but every decade or so there is some "crisis" that we're facing. Some people use the word epidemic but it's just pure sensationalism.

You're right, the popularity of drugs fluctuates. The use of amphetamines goes up every time cocaine use goes down and vice versa.

Lastly, we have to stop sending people to prison where they are beaten and raped for possession of marijuana. Wanna talk about life destroying? Let's have a conversation about the correctional system...

A B Williams

6 weeks agofrom Central Florida

Jesse - I’m sorry, your article brought back many memories and I just began typing and failed to give you credit for a well done article.

A B Williams

6 weeks agofrom Central Florida

I agree Leland. My approach to this article is a very personal one.

In school, in the 70s, everyone knew “the potheads”, they’d sleep through class, if they made it to school at all. While not all of them ended up in rehab eventually...or much worse, their world was made smaller, they became limited, by their early bad habit.

My brother was gifted, things came very easy for him, in elementary school, by middle school (junior high) he was hanging out with the wrong crowd, he started smoking pot and his mind went to pot. I saw it happen right before my eyes, he became distant and dumbed down, eventually he dropped out of school. The same with my cousin. My cousin died young, he battled drugs throughout his life and it took its toll.

My brother has somehow been spared, he has had many brushes with death and present day, he cannot get through the day (at least he believes he cannot) without a boatload of narcotics.

They were both bright, gifted, lovers of life until they were introduced to marijuana....much too young!

I’ve seen it too many times, I am not a fan of this giant bear hug between our States and legalized marijuana.

I understand that it helps people with pain, when they are terminally ill or suffering with a debilitating disease, I actually voted for medical marijuana use here in my State of Florida....but, it will not end there. There is much money in it and the backers of the legalization of recreational marijuana for everyone in every State, use the term “medicinal” to get a foot in the door and then it is just a matter of time. I know that will be the case for my State, it is just a matter of time.

In how many ways can the people of America be dumbed down?

Let me count them.

Leland Johnson

6 weeks agofrom Midland MI

Jesse- Interesting article on a controversial topic- cheers for taking it on. I have some thoughts about it.

The comparisons between marijuana, alcohol, tobacco, and all drug families is one that is understudied, and I mean that in a more historical sense. For example, most people know about the 18th ammendment to the Constitution regarding Prohibition, but not many really understand the history behind it. In the latter part of the 19th century women's groups and church groups were trying to reform societal ills caused by alcoholism. In the worst cases alcoholic men would leave their families leaving them to fend for themselves, sometimes with catastrophic consequences for the children. There were no social services back then and sometimes kids suffered severe malnutrition and even death because of the absenteism of the father. The movement was a reflection of one that occurred in Great Britain much earlier in that century. As much as 40% of Lononders were alcoholics. This prompted William Wilburforce to introduce legislation outlawing hard liquor but allowing beer, a lesser evil. It helped. 1 out of every 4 girls under the age of 15 was a prostitute and these scenarios always featured hard liquor as a crutch and facilitator. Our own country, agree or disagree, saw the wisdom in Great Britain's policies regarding alcohol and adopted similiar ones, hence Prohibition. Today the idea seems ludicrous to most Americans, but that's because we grew up in an atmosphere where alcohol is appreciated if not celebrated. It's hard for us to grasp how devestating alcoholism was to our great grandparents, but it was bad enough for them to do something about it. Again, we see alcohol as next to harmless, but what about the stats regarding roadway caused deaths? About 50% of them are alcohol related. Nearly everyone knows someone who has been killed by a drunk driver. But our society accepts it as normal. Imagine if the same statistic applied to anything else. There would be outcry and outrage for something to be done, but our culture is so given to the idea that we have a right to "check out" in the name of leisure, to put things into our bodies that make us lose sense of ourselves because it feels good regardless of long term effects or harmful effects on others whether it be on the road, or in our homes. In regard to the statistics you quoted I have two thoughts: 1. I have a bit of a problem believing them because I think people who take crack aren't obliged to fill out drug use questionaire's or take part in double blind studies, or to be forthright about their drug use. 2. As our culture moves forward with the ideas of embracing and legalizing drug use you will see statistics rise in deaths, overdoses, road kills, etc. The idea behind legalization is expansion of use. I was just commenting to some friends about how since marijuana has been legalized in my state I routinely smell it on people out in the public square. I also think statistics are very slanted when reporting data like "marijuana users are 70% less likely to develop lung cancer than tobacco smokers." Of course- that's because it was too expensive to smoke a "pack" of joints per day over a 10 year period. That data is already shifting.

One last thought- I do hold pharmaceutical companies partly responsible because for many years they told physicians that the opiates they were prescribing were addictive in less than 1% of the population, which was completely false. (the patient populace involved are those suffering from chronic pain issues) Now, in the hospital where I work and in all U.S. hospitals, opiate use has been restricted by the our government so patients who were receiving a prescription of 50 vycodiin tablets now receive less than 10 with no refills. They still have pain once the script runs out so where do they turn? To heroin. So pharm companies and dr.'s have created an opiate addiction, then cut off the patient population, which in turn has created the so called "opiate crisis." Legalizing drugs for leisure doesn't fix the problem, it only shifts, exacerbates, and creates more problems. As far as marijuana being a gateway drug, which is the main topic of your article, I think a question to be asked is this: If you ask a heroin addict, crack, meth addict, etc, if they've ever smoked pot, what do you think they'd say? If you were to ask them the order of use what do you think they'd say? I think they'd say they smoked pot first. I think you'll agree, Jesse, that human behavior has a tendency to follow a steady path of progression either for good or for bad. Habitual behavior gets compounded when practiced behavior reaches the chemical strata of human behavior, hence when a person takes up running as a hobby, if they continue routine running it won't be long before their body is demanding to be taken out for a run. It's true with weight lifters too. It's true with all human behavior. People rarely stay static. We either move in one direction or the other. It is upon this principle that I place my idea/opinion that the legalization of any drug will create a marketplace which in turn creates more users. In the minds of many legalization is tantamount to moral authority. That is, "if it's legal it's right" which is shaky ground on which to stand. Thanks for the article, Jesse, and happy holidays my friend.

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